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PHYSIOTHERAPY IN PALLIATIVE CARE Pauline Cerdor - Physiotherapist Palliative Care Unit Peninsula Health Frankston
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DEFINITION "care which provides coordinated medical, nursing and allied services for people who are terminally ill, delivered where possible in the environment of the person's choice, and which provides physical, psychological, emotional and spiritual support for patients, and support for patients' families and friends. ---- includes grief and bereavement support for the family and other carers during the life of the patient and continuing after death.“ (http://www.palliativecare.org.au)
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Palliative Care “… the active, total care of patients whose disease no longer responds to curative treatment and for whom the goal must be the best quality of life for them and their families”. What do you let the patient tell you? by Barbara Martlew quoting from Lamerton, 1980 and Doyle, 1987.
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WHERE Palliative physiotherapy is found in:- Specific palliative care wards Nursing homes General wards Oncology wards Community rehabilitation (homes)
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OBJECTIVES of TREATMENT to be as free as possible from unnecessary suffering (physical, emotional or spiritual); to maintain patient’s dignity and independence throughout the experience; to be cared for in the environment of choice; to have patient’s grief needs recognised and responded to; to be assured that families needs are also being met. (http://www.palliativecare.org.au)
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PHYSIOTHERAPY Physiotherapy in palliative care is orientated to achieve the optimum quality of life as perceived by the patient. Wholistic & problem solving approach to therapy Achieve maximum physical, psychological, social, vocational function Adapt traditional therapy to the patient’s changing function More beneficial if begins with diagnosis of cancer and continues as required through the various stages -- preventative, restorative, supportive, palliative (Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)
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Preventative Aims at restricting or inhibiting the development of disability in the course of the disease or treatment before disability occurs Education for patient and families commencing immediately after diagnosis Mobility and exercise programs. Availability of therapist as a resource for patients and families (Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)
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Restorative Rehabilitation is the objective when no or little residual disability is anticipated for some time and patients are expected to return to normal living styles Encouragement, education and treatment in achieving physical, work and lifestyle goals Specific treatments as required (Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)
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Supportive Enhance independent functioning when residual cancer is present and progressive disability is probable Encouragement, education and treatment in achieving physical, work and lifestyle goals Availability of therapist as a resource (Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)
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Palliative Primarily directed at promoting maximum comfort Maintaining the highest level of function possible in the face of disease progression and impending death (Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)
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In Brief The Chartered Society of Physiotherapy www.csp.org.uk Page 8/43 Ref: EB 04 • Prevent muscle shortening • Prevent joint contractures • Influence pain control • Optimise independence and function • Education and participation of the carer (Fulton and Else, 1997).
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Goal of Physiotherapy Determine the patient’s functional loss Estimate functional potential Implement a plan to progress from measured loss to full potential To improve quality of life To listen ‘actively and positively’ with an awareness of priorities as determined by the patient Achieve the best possible quality of life for patients and their families Availability as a resource for patient and families Frost, M The Role of Physical, Occupational and Speech therapt in Hospice: Patient Empowerment. 2001 (Martlew, B. What do you let the patient tell you. 1996) (wHO 1990)
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AIM of Physiotherapy 1 Assess and optimise the patient’s level of physical function Take into consideration the interplay between the physical, psychological, social and vocational aspects of function Understand the patients underlying emotional, pathological and psychological condition, Focus is the physical and functional consequences of the disease and/or its treatment, on the patient. Fulton and Else, 1997; p817 Chartered Society of Physiotherapy
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AIM of Physiotherapy 2 Restore the patient’s sense of self Facilitate and optimise the patient's ability to function with safety and independence in the face of diminishing resources. Maintain optimum respiratory & circulatory function Listen to patient Set realistic goals with the patient
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AIM OF PHYSIOTHERAPY 3 Prevent muscle shortening & joint contractures Influence pain control Educate in all aspects of physical function Education and participation of the carer Treat the patient with dignity – allowing them to “live until they die” Build a relationship of confidence and trust (Fulton and Else, 1997 Chartered Society of Physiotherapy). (Purtilo, R. Don’t mention it: the physical therapist in a death defying society. 1972)
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DIFFERENCES IN PALLIATIVE PHYSIOTHERAPY TREATMENT Traditional physiotherapy treatments need to be modified to accommodate the irregular changing needs of the patient Treatments are brief often less than 10 minutes and are repeated several times per day if possible Frequent rests are required Patient’s status can change suddenly and rapidly Requirement to balance ‘effort’ and ‘fatigue’
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Requirement to:- - Monitor and respond appropriately to patient’s verbal & non-verbal expressions of pain - Monitor patient very closely during and between treatments Timely communication to/with other team members is particularly important Changes in patients status Information given or obtained from patient Contribute to staff confidence with patient transfers by accurate assessment and reporting of patient’s changing transfer abilities Coordinate & participate with nursing staff in transfers of patient
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Major issues the patient and therapist face Fatigue, nausea, pain, weakness, lack of confidence, disparity between perceived & actual physical ability, drug reactions, Cachexia (major weight loss), progressive , irregular decline in ability, muscle wasting, disease progression, ascities, varying grief reactions.
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TREATMENT Assessment of patient’s physical, & transfer abilities Respiratory management/education Mobility towards maximum level independence – treatment & education Active &/or passive mobilization Pain & symptom management Exercise prescription
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TREATMENT Assessment & education in functional ADL Provision of walking aides Pain management - education - TENS Lymph management Massage Relaxation Hydrotherapy
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TREATMENT Home discharge planning with Occupational Therapist - home visit - education, patient & family - provision of aides - liaison with other palliative staff Multidisciplinary meetings Family meetings Listening and supporting
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Case Study- Mr S Male 65 years old, with SCLC, cord compression and neuropathic painS SOB on minimal exertion Chest – moist, productive cough Strength – R – 4/6; L – 3/6 Joint mobility – full functional Bed mobility – range from assist x 1 to assist x 2 Mobility –used 4ww due to pain, not walked 4+ days Pain – back and legs/hips Ascities Fatigues easily
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GOALS Improve chest status and management Increase leg strength Encourage bed mobility Achieve best possible walking mobility Liaise with wife Educate as appropriate
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TREATMENT Education - breathing techniques - SOB management - fatigue management Exercise program Assist with bed/chair transfers
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Progress to sit/stand exercises Walking in Physiotherapy gym Progress to walking with 4ww
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Education of patient in techniques to manage at home Education and support of wife, prior to discharge Liaison with Occupational Therapist
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OUTCOME Discharge home after 6.5 weeks Walking with supervision & 4ww, 10-15m Supervision with ADL Light supervision with transfers Patient was re-admitted 6 weeks later, having been active at home for that time, with increased severity of symptoms and died 7days after re-admission.
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Case 2 - Bill 83 years old, married with independent children Wood and hand craft worker Prostate Cancer, colostomy, bowel obstructions Neuropathic pain – pelvis, right side abdominal area Non-mobile when first referred
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TREATMENT Exercise routine Use overhead tracking in department mobilisation on 4ww Education in pacing activities, energy conservation Referred to rehabilitation GLR
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OUTCOME Discharged home after 4 weeks via TCP (Transition Care Program) At home 3-4 months Re-admitted to Palliative Care with increased pain Died 1 week later
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Case 3 - Graeme Colorectal cancer and caecum cancer Age 65, married with teenage son Fit and independent prior to diagnosis Presented - 3 drain tubes - large abdominal wounds - unstable gait Treatment - mobilisation with 4ww/wheel chair - exercises, - education Currently patient for 3+ months
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CRP REFERRALS RATIONALE Often small window of opportunity for patient to return home Monitor - return home - mobility - exercises Act as education resource for patient and family Treat new issues as they arise
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What do palliative patients require from a physiotherapist Flexibility Understanding both emotionally and physically Information – clarity - agreeing with other sources Education Encouragement Respect for their choices
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STATISTICS 25% of Palliative Care patients are discharged, either home or to a care facility Average length of stay --- 10 to 12 days Physiotherapist currently works 16 hours/week 15 bed ward Average 21 referrals per week Average over 22 treatments per week
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BENEFIT OF INCREASE IN HOURS 7.56% increase in daily referrals 48% increase in number of daily treatments 120% increase in the number of treatments per week 60% increase in referrals per week increase presence on the ward increase staff assistance with transfers increase in frequency of treatments attendance at team meetings and some ward rounds improved palliative approach to treatment improved interactions and involvement on ward availability for in-service greater input into patient care Availability for GLR staff and other meetings
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Personal comments Why I like working in palliative care * * * * * *
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BIBLIOGRAPHY http://www.medicineau.net.au/clinical/palliativecare/PhysioLymph.html http://www.pallcarevic.asn.au http://www.palliativecare.org.au http://www.csp.org.uk/uploads/documents/evidencebrief_palliative_EB04.pdf Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists. 1991 Purtilo, R. Don’t mention it: the physical therapist in a death defying society. 1972 Martlew, B. What do you let the patient tell you. 1996 WHO 1990 Frost, M The Role of Physical, Occupational and Speech therapt in Hospice: Patient Empowerment. 2001 Winningham, M.L. Walking Program fro People with Cancer. Getting Started. 1991 Brown, D.J. The Problem of Weakness in Patients with Cancer. 1999 Laakso, E. McAuliff, AJ. Cantlay, A. The Impact of Physiotherapy Interventions on Functional Independence and Quality of Life in Palliative Patients. 2003 Shanks, R. Physiotherapy in Palliative Care. 1982